Healthcare Provider Details

I. General information

NPI: 1720528037
Provider Name (Legal Business Name): KELLEN J KJERA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 N MORRIS ST
PORTLAND OR
97227-1541
US

IV. Provider business mailing address

1776 SW MADISON ST
PORTLAND OR
97205-1715
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-9875
  • Fax: 503-230-9877
Mailing address:
  • Phone: 971-386-2278
  • Fax: 503-224-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201609352RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0953800
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: